Lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra and, in men, the prostate. The term is more commonly applied to men—over 40% of older men are affected—but lower urinary tract symptoms also affect women. The condition is also termed prostatism in men, but LUTS is preferred.
Symptoms and signs
Symptoms can be categorised into:
Filling (storage) or irritative symptoms
Increased frequency of urination
Increased urgency of urination
Urge incontinence
Excessive passage of urine at night
Voiding or obstructive symptoms
Poor stream (unimproved by straining)
Hesitancy
Terminal dribbling
Incomplete voiding
Urinary retention
Overflow incontinence (occurs in chronic retention)
Episodes of near retention
As the symptoms are common and non-specific, LUTS is not necessarily a reason to suspect prostate cancer. Large studies of patients have also failed to show any correlation between lower urinary tract symptoms and a specific diagnosis. Also, recently a report of lower urinary tract symptoms even with malignant features in the prostate failed to be associated with prostate cancer after further laboratory investigation of the biopsy.
Causes
Benign prostatic hyperplasia (BPH)
Bladder stone
Cancer of the bladder and prostate
Detrusor muscle weakness and/or instability
Diabetes
Use of ketamine
Neurological conditions; for example multiple sclerosis, spinal cord injury, cauda equina syndrome
Prostatitis, including IgG4-related prostatitis
Urethral stricture
Urinary tract infections (UTIs)
Diagnosis
The International Prostate Symptom Score (IPSS) can be used to gauge the symptoms, along with physician examination. Other primary and secondary tests are often carried out, such as a PSA (Prostate-specific antigen) test, urinalysis, ultrasound, urinary flow studies, imaging, temporary prostatic stent placement, prostate biopsy and/or cystoscopy.
Treatment
Treatment will depend on the cause, if one is found. For example; with a UTI, a course of antibiotics would be given; appropriate medication would be administered to treat benign prostatic hyperplasia.
Lifestyle changes
Other treatments include lifestyle advice; for example, avoiding dehydration in recurrent cystitis.
Men with prostatic hypertrophy are advised to sit down whilst urinating. A 2014 meta-analysis found that, for elderly males with LUTS, sitting to urinate meant there was a decrease in post-void residual volume (PVR, ml), increased maximum urinary flow (Qmax, ml/s), which is comparable with pharmacological intervention, and decreased the voiding time (VT, s). The improved urodynamic profile is related to a lower risk of urologic complications, such as cystitis and bladder stones.
Physical activity
Physical activity has been recommended as a treatment for urinary tract symptoms. A 2019 Cochrane review of six studies involving 652 men assessing the effects of physical activity alone, physical activity as a part of a self-management program, among others. The evidence from this review states that there are important uncertainties whether physical activity is helpful in men experiencing urinary symptoms caused by benign prostatic hyperplasia.
Medications
With benign prostatic enlargement causes of LUTS, people may be offered a variety of medications (as a single drug or combining them) when there are persistent moderate symptoms:
Alpha blockers
5-alpha reductase inhibitors
Phosphodiesterase inhibitors
Muscarinic receptor antagonists
Plants extracts (phytotherapy)
Beta-3 agonist
If medical treatment fails, or is not an option; a number of surgical techniques to destroy part or all of the prostate have been developed.
Surgical treatment
Surgical treatment of LUTS can include:
Ablation procedures - used in treating both bladder tumours and bladder outlet obstruction, such as prostate conditions.
Bladder-neck incision (BNI)
Removal of the prostate - open, robotic, and endoscopic techniques are used.
Stenting of the prostate and urethra.
Transurethral resection of the prostate (TURP)
Transurethral microwave thermotherapy
Urethral dilatation, a common treatment for strictures.
Epidemiology
Prevalence increases with age. The prevalence of nocturia in older men is about 78%. Older men have a higher incidence of LUTS than older women.
Around one third of men will develop urinary tract (outflow) symptoms, of which the principal underlying cause is benign prostatic hyperplasia.
Once symptoms arise, their progress is variable and unpredictable with about one third of patients improving, one third remaining stable and one third deteriorating.
References
Further reading
NHS; Cancer Screening Programmes. Prostate Cancer Risk Management.
External links
LUTS in men - Patient.info
LUTS in women - Patient.info
Urological conditions
Symptoms and signs: Urinary system